Symmetrical peripheral gangrene in sepsis after treatment with inotropes

Jiang, Jiin-Ling; Tseng, Lin-Wei; Chang, Huai-Ren

doi:10.4103/tcmj.tcmj_25_17

Cited by 14 publications

(10 citation statements)

References 26 publications

(38 reference statements)

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“…These zones of relative hypoperfusion can be thought of as watershed areas but without any collateral supply of oxygenated blood, and norepinephrine-induced vasoconstriction of these areas and their associated microvasculature may contribute to ischemia 11 . Several individual case reports show similar findings in patients with sepsis treated with low- and high-dose norepinephrine, with all affected tissues lying distally 11–13 …”

Section: Discussionmentioning

confidence: 99%

“…11 Several individual case reports show similar findings in patients with sepsis treated with low-and high-dose norepinephrine, with all affected tissues lying distally. [11][12][13] Although the potential adverse outcomes are no reason to curtail the use of vasoactive medications, providers should know that any underlying conditions causing preexisting vascular compromise make these injuries more likely. This is demonstrated particularly well by the third case, a 79-year-old woman with poorly controlled type 2 diabetes.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Norepinephrine-Induced Peripheral Ischemia Leading to Gangrene: A Case Series

Wilson

Schafer

Goldschmidt

et al. 2021

Adv Skin Wound Care

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Norepinephrine is used in the acute care setting to establish and maintain hemodynamic stability in patients with hypotension. Although it is often a lifesaving medication, norepinephrine may lead to profound vascular insufficiency in the extremities, resulting in dry gangrene and skin necrosis. The purpose of this article is to present a case series of skin complications related to treatment with norepinephrine and review the pathophysiology behind these complications. The authors also explore risk stratification as it relates to history and clinical presentation with subsequent focus on contingencies to mitigate the adverse effects of vasoconstriction on peripheral tissues.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Norepinephrine-Induced Peripheral Ischemia Leading to Gangrene: A Case Series

Wilson

Schafer

Goldschmidt

et al. 2021

Adv Skin Wound Care

View full text Add to dashboard Cite

show abstract

“…However, the significant trauma he sustained including the grade VI liver laceration put him in a high pro-inflammatory condition. As a result, this has put the patient at risk of developing microthrombosis by reducing hepatic production of natural anticoagulants, protein C, and anti-thrombin [1, 16, 17, 29]. Moreover, he had developed septic shock secondary to an abdominal visceral infection that necessitated the use of inotropes to manage the associated hypotension.…”

Section: Discussionmentioning

confidence: 99%

Four Limb Amputation Secondary to Symmetrical Peripheral Gangrene in a Polytrauma Patient: A Case Report

Alborno

Moghamis

Kayali

et al. 2023

Case Rep Orthop Res

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Symmetrical peripheral gangrene (SPG) is a rare condition. At present, there is no clear etiology for this condition; however, it has been associated with multiple risk factors, including sepsis and coagulopathy. We present a patient who sustained a polytrauma with multiple organ injuries. During hospitalization, he developed septic and cardiogenic shock complications by disseminated intravascular coagulopathy, which led to ischemic changes in all four limbs. The patient underwent bilateral – trans-tibial and trans-radial – amputation. High level of suspicion and awareness are required to detect such a devastating condition in order to mitigate complications. We conclude that ischemic changes secondary to SPG are irreversible; subsequently, halting the disease progression is the mainstay of treatment.

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“…Symmetrical peripheral gangrene (SPG) is an uncommon yet catastrophic condition, marked by the emergence of peripheral ischemic lesions in the absence of significant vascular occlusion [ 1 ]. As a disseminated intravascular coagulation frequently linked with systemic diseases, such as sepsis, vasculitis, and states of increased blood clotting, SPG presents unique challenges [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

“…The objective of our study is to perform an in-depth review of the existing literature on SPG, with a specific focus on the role of inotropes in its pathogenesis. This study is crucial as it augments the current understanding and addresses the gaps in the scarce literature on SPG [ 1 ].…”

Section: Introductionmentioning

confidence: 99%

Relationship Between Symmetrical Peripheral Gangrene Patients and Using Vasopressors in the Intensive Care Unit

Alhumam,

Alhumaidi

et al. 2024

Cureus

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Symmetrical peripheral gangrene (SPG) is a rare yet severe condition characterized by peripheral ischemic lesions without significant vascular occlusion. Its clinical presentation includes peripheral cyanosis, mottling, and symmetrical ischemia of distal limbs, often progressing to gangrene. Recent years have seen a rise in SPG cases, with mortality rates ranging from 40% to 90%. The condition is associated with systemic diseases, such as sepsis, vasculitis, and coagulopathy. DIC frequently complicates SPG, reflecting a disturbed procoagulant-anticoagulant balance and depletion of natural anticoagulants. While vasopressor therapy, particularly high-dose administration, has been implicated in SPG pathogenesis due to sustained vasoconstriction or idiosyncratic responses, recent evidence suggests it may not be the underlying cause. Studies indicate a low incidence of ischemic limb necrosis associated with high-dose vasopressors, with DIC and shock liver potentially explaining limb ischemia instead. The characteristic temporal interval between the onset of shock liver and limb ischemic necrosis suggests a more complex pathophysiology. The role of infectious agents, such as bacteria and viruses, in SPG pathogenesis is under investigation, with both direct vascular invasion and immune-mediated mechanisms proposed. Diagnosis involves ruling out other causes of acral gangrene through clinical examination, laboratory tests, imaging studies, and biopsy. Treatment strategies aim to halt disease progression, eliminate causative factors, and prevent complications. While anticoagulants, vasodilators, and adjunctive therapies like hyperbaric oxygen show promise, the efficacy of interventions varies, emphasizing the need for individualized management. Notably, hemoadsorption has emerged as a promising treatment, demonstrating significant improvement in SPG cases. Amputation remains a last resort option in irreversible cases. Early recognition and multidisciplinary management are crucial for improving outcomes. Further research is needed to better understand SPG's etiology and develop effective treatments through collaborative efforts.

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Symmetrical peripheral gangrene in sepsis after treatment with inotropes

Cited by 14 publications

References 26 publications

Norepinephrine-Induced Peripheral Ischemia Leading to Gangrene: A Case Series

Norepinephrine-Induced Peripheral Ischemia Leading to Gangrene: A Case Series

Four Limb Amputation Secondary to Symmetrical Peripheral Gangrene in a Polytrauma Patient: A Case Report

Relationship Between Symmetrical Peripheral Gangrene Patients and Using Vasopressors in the Intensive Care Unit

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